2. CIRCUIT COURT FOR PRINCE GEORGE'S COUNTY MARYLAND
4. CONFIDENTIAL ALTERNATIVE DISPUTE RESOLUTION (ADR) STATEMENT
6. Statement must be received no later than fifteen (15) business days prior to the scheduled ADR Conference.

   
   

   Do not file this form with the Clerk's Office.

   Do not provide to opposing counsel/parties.

   This form will not be retained by the ADR Offices, the Clerk's Office or the Assigned ADR Judge.

8. Case Number*
10. Case Caption*
12. ADR Conference Date*
    ADR Conference Date
13. Trial Date*
    Trial Date
15. Provide the name, title, office telephone number, cellphone number and email address of each person who will be participating in the ADR Conference. Designate which person will have settlement or negotiating authority.*
17. Nature of the Case: A brief statement of the facts including date(s) and location(s).*
19. Claims and / or Defenses: Each party is to provide specific claims and/or defenses as asserted by that party.*
21. Weak Point(s) of the Case*
23. Strong Point(s) of the Case*
25. Is medical necessity at issue?*

    1. Yes
    2. No
26. Is reasonableness of bills at issue?*

    1. Yes
    2. No
27. Liability is:*

    1. In serious dispute
    2. Not in serious dispute
    3. Conceded
29. Is permanency an issue?*

    1. Yes
    2. No
30. Permanent injuries being claimed:
32. An Independent Medical Evaluation:*

    1. Has been scheduled
    2. Has been completed

    1. Has not been scheduled or completed
34. Relief Sought:*
36. Total medical expenses to date:*
38. Future medical expenses:*
40. Loss of earnings to date:*
42. Future of loss of earnings:*
44. Punitive damages:*
46. Other special damages:*
48. Nature of Damages:*
50. TOTAL DAMAGES:*
52. Non-Monetary Relief:*
54. Have there been settlement negotiations?*

    1. Yes

    1. No
56. Terms to settle:*
57. Amount willing to settle for:*
59. Attorney*
60. Telephone*
61. Date*
    Date
63. Additional Information

    Additional information may be uploaded or submitted on a separate page and emailed to ADRCoordinator@mdcourts.gov

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65. 1. Receive an email copy of this form.
66. Email address

    This field is not part of the form submission.

67. Submit Submit and Print

* indicates a required field